1770833386 NPI number — LA BUENA VIDA PHARMACY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770833386 NPI number — LA BUENA VIDA PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA BUENA VIDA PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770833386
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
51-335 CESAR CHAVEZ ST
Provider Second Line Business Mailing Address:
SUITE 116
Provider Business Mailing Address City Name:
COACHELLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92236-1547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-398-8866
Provider Business Mailing Address Fax Number:
760-398-9966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51-335 CESAR CHAVEZ ST
Provider Second Line Business Practice Location Address:
SUITE 116
Provider Business Practice Location Address City Name:
COACHELLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92236-1547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-398-8866
Provider Business Practice Location Address Fax Number:
760-398-9966
Provider Enumeration Date:
09/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
YIK
Authorized Official First Name:
SIMONE
Authorized Official Middle Name:
AOY YEE
Authorized Official Title or Position:
PRESIDENT/PIC
Authorized Official Telephone Number:
760-398-8866

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY51158 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GY413A . This is a "MEDICARE PART B" identifier . This identifiers is of the category "OTHER".
  • Identifier: 56-45518 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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